Genetic heterogeneity and predominance of blaCTX-M -15 in cefotaxime-resistant Enterobacteriaceae isolates colonizing hospitalized children in Tunisia.

Extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae have emerged as important nosocomial pathogens. Community infections by these organisms have been also reported and were associated with previous intestinal colonization. We aimed to characterize cefotaxime-resistant Enterobacteriaceae (CTX-R-En) isolated from hospitalized children in a Tunisian paediatric ward. Seventy CTX-R-En isolates were collected from 227 rectal swabs from hospitalized children in a paediatric ward. Antimicrobial susceptibility testing was determined according to the EUCAST guidelines. Isolates were characterized by polymerase chain reaction (PCR, genes encoding: ESBLs, pAmpC, carbapenemases, plasmid-mediated quinolone resistance, virulence factors in Escherichia coli and Klebsiella pneumoniae isolates, occurrence of classes 1 and 2 integrons, phylogenetic groups of E. coli isolates, ERIC-PCR and PCR-based replicon typing) and conjugal transfer experiments. In total, 65 out of 227 (28·6%) hospitalized children were colonized with CTX-M-R-En, and 70 isolates were identified. Isolates were 59 ESBL-, 7 plasmidic-AmpC (pAmpC)-, 3 ESBL+pAmpC-, and one ESBL+carbapenemase producers. The following bla genes were identified: blaCTX-M-15 (n = 54), blaCTX-M-1 (n = 5), blaCTX-M-9 (n = 2), blaCTX-M-13 (n = 1) and blaCTX-M-14 (n = 1), blaCMY-2 (n = 5), blaCMY-4 (n = 4), blaACC-1 (n = 1) and blaOXA-48 (n = 1). Our results showed that hospitalized children were colonized with various CTX-R-En-producing several beta-lactamase enzymes.

Polymorphism of ftsI gene in Haemophilus influenzae and emergence of cefotaxime resistance in two Tunisian hospitals.

The decreased affinity to ß-lactams in Haemophilus influenzae is usually caused by specific alterations in penicillin-binding protein 3 due to varieties of substitutions in ftsI gene. This study aimed to characterize the polymorphism of ftsI gene in 19 H. influenzae strains, isolated between 2014 and 2016 (different resistance phenotypes to ß-lactams (n = 9) and susceptible strains (n = 10) used for comparative purposes). All strains were characterized for capsular type by PCR and agglutination tests and for ß-lactam resistance by amplification and sequencing of ftsI. Biotyping and clonality were performed by API-NH and pulsed-field gel electrophoresis, respectively. Four strains were ß-lactamase-negative ampicillin-resistant and five were ß-lactamase-positive clavulanic-acid-resistant. One strain from each group was resistant to cefotaxime. Our isolates belonged mainly to biotype IV and I and were non-typeable and genetically unrelated. According to mutation profiles of their ftsI, strains were classified as group I (n = 3), group II (n = 4), group-III-like (n = 1) and group III (n = 1). All group II strains were further classified as subgroup IIb, except for one strain, which harboured a new mutation (N422I). Ampicillin MICs of ß-lactamase-negative ampicillin-resistant strains were 6 to 12 times the MICs of susceptible strains. Only bla TEM-1 was detected in ß-lactamase-positive clavulanic-acid-resistant strains, and was responsible for high MICs for ampicillin (>256 mg/L), whatever the ftsI mutational resistance group. The emergence of cefotaxime-resistant isolates in our country is a matter of concern and requires strict surveillance and rationalization of antibiotic use to preserve these molecules.

Epidemiological and immunochemical parameters of monoclonal plasma cell dyscrasias of 2121 cases in Algeria.

BACKGROUND: Plasma cell dyscrasias (PCD) are a heterogeneous group of diseases characterized by the expansion of monoclonal bone marrow plasma cells that produce a monoclonal immunoglobulin (M-component). PURPOSE: This is a retrospective study that describes the epidemiological, immunochemical features and etiology of monoclonal gammopathies diagnosed between 1998 and 2016 in the Teaching Hospital Beni-Messous of Algiers. PATIENTS AND METHODS: 2121 cases of monoclonal gammopathies (MG) were collected during this period. Serum/urine protein electrophoresis, serum/urine immunofixation and serum free light chain measurements were used to demonstrate M protein. RESULTS: The middle age of the patients at the time of the diagnosis were 62.96 ± 13.19 years with extremes ranging from 07 to 99 years. The study included 1013 (47, 76 %) men and 1108 (52, 23 %) women with a sex ratio 0,91. Isotypes repartition was: IgG (60.91 %), IgA (17.91 %), light chain (10.46 %), IgM (6.6 %), IgD (1.03 %) and IgE (0.09 %) of cases. The most frequent diagnosis was: Multiple Myeloma (55.20 %), followed by monoclonal gammopathy of undetermined significance (34.13 %). CONCLUSION: In our study, two particularities were noted. There is no male predominance in Algerian PCD patients. Moreover, we observed a higher frequency of light chain multiple myeloma and lower frequency of IgM isotype compared to western studies.

Virulence determinants, biofilm production and antimicrobial susceptibility in Staphylococcus aureus causing device-associated infections in a Tunisian hospital.

Staphylococcus aureus is a clinically relevant pathogen that causes device-related infections (DRI) driven by several virulence factors. This study characterized S. aureus isolates involved in DRI in Tunisian patients. Forty consecutive S. aureus strains causing DRI and 47 randomly selected S. aureus strains causing non-device-related infections (NDRI) were collected. All strains were screened phenotypically for antibiotic susceptibility and biofilm forming ability. They were investigated for accessory gene regulator (agr) types, biofilm encoding genes (icaADBC), adhesins, leukotoxins, toxic shock toxin, enterotoxins and exotoxins encoding genes by polymerase chain reaction. Meticillin-resistant S. aureus (MRSA) strains were further characterized by staphylococcal cassette chromosome mec (SCCmec) typing. MRSA rates among DRI and NDRI isolates were 23% and 49% (P=0.02), respectively. The DRI isolates formed biofilm more frequently (n=32) than the NDRI isolates (n=28) (P=0.04), with predominance of the moderate biofilm producer category (P=0.027). All biofilm-positive isolates except four harboured icaADBC genes. A significant difference was observed between DRI and NDRI isolates for fnbA (53-77%), spa (45-26%), sdrD (80-55%) and sen (33-11%) genes. DRI strains were agrI (48%) and agrII (30%) types, whereas NDRI strains were agrI (36%) and agrIII (43%) types. SCCmec type IV was carried by 50% of MRSA isolates. This study highlights the virulence potential displayed by S. aureus isolated from DRI in comparison with NDRI.

Bicyclist's vulva: Diagnostic and therapeutic aspects.

The authors report a case of a rare vulvar condition in a young cyclist, known as bicyclist's vulva. The diagnosis was based on the clinical context (intensive cycling training with repeated saddle sores, responsible for painless unilateral swelling of the labium majus to a significant size and functional discomfort). Imaging examinations were used to characterize the lesion and its relationship with the pelvic organs. The lesion was composed of connective tissue, poorly demarcated and heavily collagenised without necrotic or hemorrhagic areas. Large cicatricial collagen bundles were observed. The fibroblasts revealed no atypia and just a few scattered undilated vessels ere noted. Special staining did not reveal any amyloid deposits. A complementary immunohistochemical analysis with anti-CD 34 antibody showed vascularization that was homogeneous and morphologically normal. The treatment was surgery, and in our case the cosmetic and functional impact of wide surgical excision of the lesion was improved by in situ injection of autologous fat. The pathology findings enabled us to rule out other perineal tumors such as aggressive angiomyxoma of the vulva and to describe the lesion microscopically.

Endometrial cancer in elderly women: Which disease, which surgical management? A systematic review of the literature.

OBJECTIVE: Endometrial cancer primarily affects elderly women. The aim of the present literature review is to define the population of elderly women with this disease and to define the characteristics of this cancer in elderly people as well as its surgical treatment. MATERIALS AND METHODS: A systematic review of the English-language literature of the last 20 years indexed in the PubMed database. RESULTS: Endometrial cancer is more aggressive in elderly women. However, surgical staging performed in elderly patients is often not concomitant with the disease's aggressiveness in this group. Mini-invasive surgery is performed less often, for no obvious reason. Of note, oncogeriatric evaluation was not usually ruled out to determine the most appropriate surgical modality. CONCLUSION: Studies are needed to evaluate surgical management of endometrial cancer in elderly women, notably with the aid of oncogeriatric scores to predict surgical morbidity.

A comparative study of antimicrobial resistance rates and phylogenetic groups of community-acquired versus hospital-acquired invasive Escherichia coli.

OBJECTIVES: Escherichia coli is the leading cause of various infections, both in community and nosocomial settings. Our objective was to determine the antibiotic resistance rates and the phylogenetic groups of invasive E. coli and to assess the relationship between these characteristics according to the community or nosocomial origin of the strains. MATERIALS AND METHODS: One hundred non-redundant E. coli strains, causing invasive infections, were collected and investigated between 2010 and 2012. The phylogenetic groups were determined by triplex PCR. The statistical analysis was performed with Pearson χ(2) test and P-values below 0.05 were considered as statistically significant. RESULTS: Sixty-three strains were community-acquired (CA) and 37 were hospital-acquired (HA). The resistance rates among CA and HA strains were respectively: cefotaxime (11.1/37.8%), ciprofloxacin (19/43.2%), amikacin (3.2/27.2%), and cotrimoxazole (42.8/64.8%). E. coli strains caused bacteremia (CA=34.9%; HA=83.7%), peritonitis (CA=58.7%; HA=13.5%), appendicitis (CA=3.2%; HA=2.7%), and cholecystitis (CA=3.2%; HA=0%). The distribution of phylogenetic groups among CA and HA strains was: A (25.4/18.9%), B1 (9.5/16.2%), B2 (23.8/37.8%), and D group (41.3/27%). High resistance rates to cefotaxime (P=0.02), ciprofloxacin (P=0.01), amikacin (P=0.001), and cotrimoxazole (P=0.05) were statistically significantly associated with a nosocomial origin. CONCLUSION: Our results prove the diversity of phylogroups among E. coli invasive strains whatever their origin, and a higher antibiotic resistance rate in nosocomial strains. An adequate use of antibiotics and applying strict hygiene measures would limit the transmission and selection of these bacteria in hospital as well as in community settings.

Emergence of carbapenem-resistant OXA-48 carbapenemase-producing Enterobacteriaceae in Tunisia.

We screened 21 extended spectrum ß-lactamase-producing Enterobacteriaceae with reduced susceptibility to carbapenems for carbapenemase production. Five strains (four Klebsiella pneumoniae and one Citrobacter freundii) showed carbapenemase production, which was identified as OXA-48. The bla(OXA-48) gene was detected on ~54 kb plasmids belonging to IncA/C in one case. Two isolates harboured IS1999, which is involved in bla(OXA-48) mobilization. Carbapenem resistance in enterobacteria should be regarded as an emerging clinical problem in our hospital and necessitates rigorous surveillance in order to limit its spread.

Virulence determinants, phylogenetic groups and fluoroquinolone resistance in Escherichia coli isolated from cystitis and pyelonephritis.

AIM OF THE STUDY: The aim of this study is to assess the relation between virulence genotype, phylogenetic group and susceptibility to fluoroquinolones and the urinary tract infection type including pyelonephritis and cystitis due to Escherichia coli. MATERIALS AND METHODS: Between 2006 and 2007, 129 non-duplicate E. coli isolates from pyelonephritis (n=56) and cystitis (n=73) were prospectively collected. The antibiotic susceptibility was done by disk diffusion method. The phylogenetic groups, A, B1, B2 and D and 18 virulence genes were determined by multiplex PCR. Statistical analysis was done with the Pearson χ2 test, Mann-Whitney U-test, Kruskal-Wallis test and stepwise multivariable logistic regression analysis, P values below 0.05 were considered statistically significant. RESULTS: For the pyelonephritis group, sex ratio was 0.3, the median age for women was 30 years and for men it was 54 years. For the cystitis group, sex ratio was 0.4, the median age for women was 41.5 years and for men it was 67.8 years. Significant statistical correlations were found between pyelonephritis isolates and susceptibility to ciprofloxacin (P=4 10(-5)), papG allele II (P=2 10(-6)), hlyA (P=10(-03)), iroN (P=0.04), iha (P=0.03) and ompT (P=0.03) virulence genes, high virulence score (P=0.008) and B2 phylogenetic group (P=0.03). In multivariate logistic regression analysis, papG II as predictor of pyelonephritis, no correlation could be established for the cystitis group. CONCLUSION: Our findings argue for a direct link between pyelonephritis, virulence factors, susceptibility to fluroquinolones and B2 phylogenetic group among uropthogenic E. coli.

Nosocomial outbreak of imipenem-resistant Pseudomonas aeruginosa producing VIM-2 metallo-ß-lactamase in a kidney transplantation unit.

BACKGROUND: Twenty four non replicate imipenem resistant P. aeruginosa were isolated between January and November 2008, in the kidney transplantation unit of Charles Nicolle Hospital of Tunis (Tunisia). This study was conducted in order to establish epidemiological relationship among them and to identify the enzymatic mechanism involved in imipenem resistance. METHODS: Analysis included antimicrobial susceptibility profile, phenotypic (imipenem-EDTA synergy test) and genotypic detection of metallo-ß-lactamase (MBL) (PCR), O-serotyping and pulsed-field gel electrophoresis. RESULTS: All strains showed a high level of resistance to all antimicrobials tested except to colistin. The presence of MBL showed concordance between phenotypic and genotypic methods. Sixteen isolates were identified as VIM-2 MBL-producers and 13 of them were serotype O4 and belonged to a single pulsotype (A). CONCLUSIONS: This study describes an outbreak of VIM-2-producing P. aeruginosa in a kidney transplantation unit. Clinical spread of blaVIM-2 gene is a matter of great concern for carbapenem resistance in Tunisia.

Clinical isolates of Pantone-Valentine leucocidin- and gamma-haemolysin-producing Staphylococcus aureus: prevalence and association with clinical infections.

Pantone-Valentine leucocidin (PVL) and gAMMA-haemolysin (Hlg) are members of the synergohymenotropic toxin family produced by Staphylococcus aureus and encoded by pvl and hlg genes, respectively. Many reports describe an association between PVL toxin and necrotic lesions involving skin and mucosa. The aim of this study was to determine the prevalence of S. aureus strains carrying pvl and hlg genes and to investigate a possible relationship between pvl- and hlg-positive S. aureus with specific clinical presentations. Between January 2005 and July 2007, a total of 143 S. aureus strains including 58 meticillin-resistant S. aureus (MRSA) and 85 meticillin-susceptible S. aureus were screened for pvl and hlg genes by multiplex polymerase chain reaction. These strains were isolated from 141 patients for whom demographic and clinical data were recorded. Thirty-one (21.7%) and 77 (53.7%) isolates were positive for pvl and hlg genes, respectively. Twenty-one (67.7%) pvl-positive strains were MRSA (P = 0.001). Among pvl-positive strains, 16 (51.6%) were community-acquired. There was a strong association between pvl genes and skin and soft tissue infections, especially abscesses (60% of strains; P = 0.008) and furunculosis (55.5% of strains; P = 0.036). Our findings confirmed the association between pvl-positive strains, cutaneous infections and meticillin resistance in S. aureus.

[Bacteriologic profile of bacteremia due to multi-drug resistant bacteria at Charles-Nicolle Hospital of Tunis]. / Profil bactériologique des bactériémies à germes multirésistants à l'hôpital Charles-Nicolle de Tunis.

OBJECTIVE: The authors had for aim to evaluate the place of multi-drug resistant bacteria (MDR) in nosocomial bacteremia. MATERIALS AND METHODS: A retrospective study was carried out at the Microbiology laboratory of Charles Nicolle hospital of Tunis (2001-2003). One hundred and ninety-five isolated MDR [third generation cephalosporin resistant enterobacteria, methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter baumannii and Pseudomonas aeruginosa resistant to ceftazidime and imipenem]. An automated system was used to detect bloodstream infections. Microorganism identification was performed by conventional methods and antibiotic susceptibilities were determined by the disk diffusion method. RESULTS: MDR bacteria were resistant to third generation cephalosporins (29%), A. baumannii (24%), P. aeruginosa (24%), and MRSA (10%). ERC3G were resistant to aminosides and fluorquinolones. A. baumannii and P. aeruginosa had high resistance rates. Associated resistance rates in MRSA were moderate. CONCLUSION: MDR bacteria are of great concern in our hospital. This situation emphasizes the importance to maintain rigorous measures of hygiene as well as adapted antibiotic prescriptions.

[Complications and sequelae of benign thyroid surgery]. / Complications et séquelles de la chirurgie thyroïdienne bénigne.

A series of 640-operations performed on benign thyroid gland during 8 years is presented. The pre and post operative mortality is 0.62 per cent. Late recurrent nerve paralysis occurred in 2.6 per cent. 27 patients had transit hypocalcemia and 8 had permanent hypoparathyroidism or 1.2 per cent. These complications has been studied in relation with patient benign thyroid affection and operation. In case of thyroidectomy without search for recurrent laryngeal nerve, nervous paralysis are frequent when if parathyroid gland are rare, for these lata are protected. Systematic dissection of recurrent nerve reduce nervous sequelae, but increase hypoparathyroidism, mainly by devascularisation of parathyroids glands. Complications and sequelae of thyroid surgery can yet be reduced by a rigorous surgical technic, a most sure experience and a systematic dissection of recurrent nerve and gland parathyroid in case of bilateral operation.